MILITARY MEDICINE, 178, 12:1328,2013
Effect of Center-Based Counseling for Veterans and Veterans' Families on Long-Term Mental Health Outcomes Meaghan O'Donnell, PhD*; Tracey Varker, PhD*; Desmond Perry, PhDf; Andrea Phelps, PhD* ABSTRACT The Veterans and Veterans Families Counselling Service (VVCS), established by the Australian government, plays a pivotal role in providing mental health services to veterans and their families. This research explored the impact of center-based psychological counseling on depression, anxiety, stress, and alcohol use severity. A stratified sample of VVCS clients were invited to participate in this study. Data were collected on intake to the program, at the fifth counseling session, and 12 tnonths after the commencement of counseling. Repeated-measures general linear model analyses were conducted to examine the impact of center-based counseling on depression, anxiety, stress, and alcohol severity over time. VVCS center-based counseling resulted in a significant reduction in depression, anxiety, stress, and alcohol use severity after five sessions, and these itnprovements were maintained over the next 12 tnonths. Despite these improvements, however, participants continued to report tnoderate-to-severe levels of mental health problems. VVCS center-based counseling successfully reduced depression, anxiety, stress, and alcohol use sytnptom severity of veterans and their families. However, the clinical profiles of this population are often complex and challenges retnain in terms of addressing the mental health needs of this group.
INTRODUCTION It has been widely recognized that military personnel may experience rnental health issues following deployrnent. Although much attention is paid to post-traumatic stress disorder (PTSD), evidence suggests that depression, anxiety, and alcohol use disorders are just as common.' After the Vietnam War the Australian government established the Vietnam Veterans Counselling Service (VVCS). This service aimed to provide psychological care for veterans who were experiencing physical and emotional difficulties as a consequence of their military service. Today, VVCS is a primary provider of Australian community-based mental health services to veterans and their families. The service was recently renamed the Veterans and Veterans Families Counselling Service in recognition of the broader client group including contemporary (post-Vietnam) veterans and family mernbers. VVCS operates within the Department of Veteran Affairs' mental health policy frarnework focusing on improving access to a comprehensive range of mental health services for veterans and their family members.^ There are currently 15 VVCS centers across Australia that provide both individual counseling and group programs to Australian veterans, their families, and eligible Australian Defence Force personnel. Services are provided for a wide range of war- and service-related issues such as relationships and family problems, alcohol and other drugs problerns, and psychological problems such as PTSD, depression, anxiety, problematic anger, and sleep difficulties. Access to these *Australian Centre for Posttraumatic Mental Health and of Psychiatry, University of Melbourne, Level 1. 340 Albert Melbourne, VIC 3002, Australia. tVeterans and Veterans' Families Counselling Service. of Veterans' Affairs Australia, Level 6, 280 Elizabeth Street. 2010. GPO Box 3994, Sydney, NSW 2001, Australia. doi: 10.7205/MILMED-D-13-00058
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Department Street, East Department Surry Hills
services is based on self/family member refetral, or medical practitioner refeiTal. Counseling is provided by registered psychologists or social workers across a range of programs that include individual therapy, couples/family therapy, and case management. Informal client feedback indicates that the counseling interventions provided by VVCS are effective, but there has never been an independent, longitudinal examination of the impact of these VVCS center-based counseling services on rnental health outcomes. The aim of this study was to examine the outcomes of VVCS center-based counseling practiced under naturalistic conditions. These conditions include usual providers, patients, payment mechanisms, and patient/provider choice of treatment. The aim of this study was also to explore whether VVCS center-based psychological counseling resulted in sustained improvements in the mental health of veterans and their family members across time. METHOD The study protocol was approved by the Department of Veterans' Affairs Human Research Ethics Committee. The study used data routinely collected by VVCS on intake to counseling and at session five, as well as data collected for this study at 12-months after counseling. The preexisting decision to routinely collect data at session five was based on earlier VVCS data that had shown that the average period of engagement of VVCS clients was five sessions, and to standardize the time at which post-treatment data were collected and VVCS decided to choose session five. Participants Participants met entry criteria for this study if they presented to VVCS with moderate-to-severe symptoms of depression or anxiety, or alcohol misuse, and if they completed at least five sessions of VVCS center-based counseling.
MILITARY MEDICINE, Vol. 178, Decetnber 2013
Center-based Counseling Long-Term Mental Health Outcomes
A total of 4,327 veterans and their family members met entry criteria and completed the intake questionnaire between August 2009 and August 2010, Of these, 685 completed at least 5 sessions of intervention and provided data at this time point, and 312 (46%) completed the 12-month follow-up questionnaire (Fig, 1), Demographic information of the final group of 312 participants is presented in Table I, A two-staged compléter analysis was conducted to inform the generalizability of the study results. In the first analysis, those in the final group (moderate/severe self-reported depression, anxiety, or alcohol symptoms at intake, and completion of the session five assessment and 12-month follow-up assessment, n = 312) were compared to those who failed to complete outcome measures at the fifth session or 12-month follow-up (« = 4,015), The two groups differed on era of service (;i:^(l, N = 4,327) = 29,80, p < 0,001) with a smaller proportion of contemporary veterans in the study sample (52%), relative to the noncompleter group (67%), Completers also had significantly higher levels of self-reported intake anxiety than noncompleters (r(4,325) = 2,66, /; < 0,01), and higher levels of self-reported stress at intake relative to noncompleters (r(4,325) = 2,32, p < 0,05), There were no differences between the two groups in regards to gender or self-reported depression severity or alcohol use severity. In the second compléter analysis, those who completed all three assessments were compared to those who completed the intake and session five assessment but not the 12-month follow-up. Participants who completed the 12-tTionth follow-up assessment did not differ from those who did not complete it in terms of self-reported intake depression, anxiety, and alcohol
Data available from N=5495 clients' service wide
Tl: n=4327 clients met eligibility criteria tor having moderate to severe depression, anxiety or alcohol sytnptoms T2:n = 685(16%ofthe eligible sample) had fifth counselling session data available
T3: Self report questionnaires completed by n=312 clients, 12 months after intake (46% response rate) FIGURE 1.
Flow chart of clients' progression through the study.
MILITARY MEDICINE, Vol, 178, December 2013
TABLE I.
Demographic Characteristics of the Satnple (N = 312) n (%)
Gender Male Female Status Veterans Partners Sons/Daughters Defence Referred" Other'' Age Employment Currently Employed Not Cun'ently Employed Days Worked Per Week for Those Who Are Employed Type of Therapy Provided by VVCS Individual Therapy Couples Therapy Average Number of Counseling Sessions
170(54) 162(46) 128(41) 89 (29) 59(19) 19(6) 17 (5) M = 51,29(SD= 14,63) 128(41) 184(59) M = 4,46(SD= 1,42)
284(91) 26(8) M= 11.35 (SD = 6.30); Median = 10; Range = 2-40
"Australian Defence Force members who had been referred via the Defence Memorandum of Understanding, ''Those who were granted services for compassionate reasons,
use scores. Participants who completed the 12-month follow-up assessment had significantly higher levels of self-reported stress at intake (f(683) = 2,35, p < 0,05),
Measures Mental Health
The Depression Anxiety Stress Scales (DASS-21; see Reference 3), a 21-item self-report measure used to assess severity of depression, anxiety, and stress, was administered at intake, session five, and 12-month follow-up. Individuals were required to indicate the presence of a symptom over the previous week. Good levels of reliability and validity were reported, with Cronbach's a of 0,94, 0,87, and 0,91 reported for the three subscales,** Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT; see Reference 5), The AUDIT is a 10-item, self-report instrument developed by the World Health Organization as a screening tool sensitive to early detection of risky and high-risk drinking,'' A score of eight or more is associated with harmful or hazardous drinking and a score of 13 or more in women or 15 or more in men is likely to indicate alcohol dependence,^
Procedure VVCS counselors administered the intake assessment and the assessment at the end of the fifth session of counseling. The study researchers sent a self-report questionnaire that contained the DASS-21 and the AUDIT at 12 months following completion of the study (session five). Questionnaires were returned in a replied paid envelope.
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Center-based Counseling Long-Term Mental Health Outcomes Design and Statistical Analyses
In this study we used a single group design with pre-, post-, and follow-up assessments. Four sets of repeated-measures general linear model (GLM) analyses were conducted to examine whether there were changes in outcome following center-based VVCS counseling in the short term, and whether these changes were maintained over time. Outcomes for these four sets of analyses were severity of depression, stress, anxiety, and alcohol use. The primary analyses looked at differences in symptoms across time (n = 312). Secondary analyses were conducted to investigate the role of gender, client status, and era of service on changes in symptoms across time and to compare the VVCS counseling sample's 12-month depression, stress, and anxiety follow-up results to community norms. To examine the characteristics of those with moderateto-severe symptoms who responded to VVCS center-based treatment and those who did not, we conducted further exploratory analyses. A total score for affective distress was calculated (i.e., the sum of the three DASS-21 subscales), and an affective distress change score was calculated for each participant. The change score was the difference between the intake DASS-21 total score and the 12-month follow-up DASS-21 total score. To explore the degree to which participants' levels of affecfive distress improved in a clinically reliable way, we categorized paiticipants in terms of "treatment responders" and "treatment nonresponders." Clinically reliable treatment response was defined as a decrease in DASS-21 severity score of at least 15 points at 12-month follow-up (relative to intake). This reliable change index was calculated using Devilly's^ reliable and clinical change generator, which is based on the formula of Jacobson and Traux.' These authors suggest that a reliable change index larger than 1.96 (/; < 0.05) is unlikely to occur without actual change in the individual. Reliability data for DASS-21 severity used in the reliable change calculations were obtained from the thesis of McGrail,** because of the fact that reliability for the total DASS-21 score has not been previously reported by the authors of this measure. RESULTS
Depression Severity As can be seen in Table II, depression severity changed significantly over time from intake to 12-month follow-up (f (2,620) = 116.00, p < 0.001), with effect size analyses indicating that this represented a moderate-to-large clinical effect (Hedges g = 0.75). Within-subjects contrasts showed that the significant decrease in depression severity took place between intake and the fifth session (F(\,31O) = 218.51, p < 0.001), with some of the treatment gains lost by the 12-month follow-up (f (1,310) = 5.4i,p< 0.05). Despite this, however, participants were still less depressed at 12-month follow-up than when they originally started counseling. Repeated-measures GLM analyses revealed a significant
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main effect for era of service (F( 1,145) = 4. 40, p < 0.05). This showed that contemporary veterans were significantly less depressed than older veterans. The level of depression in the overall VVCS client group 12 months after treatment, however, was significantly greater than that of depression in a non-treatment-seeking community sample (see Table III).
Anxiety Severity Anxiety severity declined significantly over time (F(2,620) = 81.00, p < 0.001), and this represented a moderate clinical effect (Hedges g = 0.63). Within-subjects contrasts showed that there was a significant decline in level of anxiety between intake and the fifth session (F(l,310) = 128.33, p < 0.001), with these improvements being maintained over time (between the fifth session and 12-month follow-up). Analyses identified a significant interaction effect for gender on anxiety severity outcomes (see Table II), with females reporting greater improvements in anxiety severity over time (Hedges g= 0.84) than males (Hedges g= 0.46) (see Table IV). Further analyses revealed a significant main effect for era of service (/^(1,145) = 6.30, p < 0.05). Repeated-measures analyses of variance showed that contemporary veterans had much greater improvements in anxiety severity over time (Hedges g = 0.72) compared to older veterans (Hedges g = 0.36). Although this suggests that contemporary veterans as a whole were experiencing less anxiety than older veterans, generally VVCS clients had significantly greater anxiety severity at 12-month follow-up than a non-treatment-seeking community sample (see Table III).
Stress Severity Stress severity changed significantly over time (F(2,620) = 114.93, p < 0.001 ), and this represented a significant moderateto-large clinical effect (Hedges g = 0.76). Within-subjects contrasts showed that there was a significant dechne in level of stress between intake and the fifth session (F(l,310) = 201.93, p < 0.001), and this was maintained between the fifth session and 12-ir)onth follow-up. Further analyses revealed a significant main effect for era of service (f( 1,145) = 4.13, p < 0.05), with contemporary veterans experiencing less stress than older veterans. In addition, contemporary veterans had far greater improvements in stress severity over time (Hedges g = 1.00) compared to older veterans (Hedges g = 0.58). In spite of these improvements, however, overall clients had significantly greater stress severity at 12-month follow-up than a non-treatment-seeking community sample (see Table III).
Alcohol Severity The GLM analysis showed that alcohol use severity declined significantly over time (F(2,622) = 13.63,/? < 0.001), although this difference was not clinically significant (Hedges g= 0.12). Within-subjects contrasts showed that there was a significant decrease in alcohol use severity between intake and the fifth
MILITARY MEDICINE, Vol. 178, December 2013
Center-based Counseling Long-Term Mental Health Outcomes
TABLE II.
Repeated-Measures GLMs for Changes in Depression, Anxiety, Stress, and Alcohol Use Severity Score Over Time Time
Depression (Whole Sample) Males Females
Veterans Other
Contemporary Veterans Older Veterans
Anxiety (Whole Sample) Males Females
Veterans Other
Analysis
n
Intake M(SD)
Fifth Session M(SD)
12-Month Follow-up M (SD)
311 169 142
23.20(10.84) 23.73(10.69) 22.66(11.01)
13.41 (10.77) 14.00(10.63) 12.72(10.96)
14.99(11.10) 16,01 (11.31) 13.77(10.76)
147 164
23.6! (10.55) 22.91 (11.10)
13.51 (10.22) 13.33(11.30)
15.03(10.90) 14.95(11.31)
63 84
22.73(10.55) 24.26(10.56)
12.03 (9.07) 14.62(10.93)
12.70(10.50) 16.79(10.92)
311 142
17.46(10.39) 16.54(10.96) 18.55(9.63)
11.24(9.66) 11.54(10.05) 10.97(9.19)
11.19(9.57) 11.74(9.79) 10.54(9.29)
147 164
16.18(10.67) 18.61 (10.05)
10.91 (9.72) 11.61 (9.61)
11.10(9.43) 11.27(9.72)
169
(dlIF
Time Time Condition Time X Condition Time Condition Time X Condition Time Condition Time X Condition Time Time Condition Time X Condition Time Condition Titne X
Contemporary Veterans Older Veterans
63 84
15.33(10.85) 16.81 (10.54)
8.44 (7.75) 12.76(10.65)
8.48 (7.88) 13.07(10.04)
Condition Time Condition Time X
Stress (Whole Sample) Males Females
Veterans Other
Contemporary Veterans Older Veterans
311 169 142
26.48 (9.72) 26.83 (9.96) 26.06 (9.45)
17.84(10.52) 18.25(10.65) 17.35(10.37)
18.77(10.50) 19.87(10.96) 17.45(9.81)
147 164
26.52 (9.67) 26.44 (9.80)
17.59(10.38) 18.06(10.67)
18.82(10.87) 18.72(10.19)
63 84
26.10(8.79) 26.83(10.33)
15.81 (8.45) 18.93(11.26)
16.32(10.58) 20.69(10.78)
Condition Time Time Condition Time X Condition Time Condition Time X Condition Time Condition Time X
Aleohol Use (Whole Sample) Males Females
Veterans Other
Contemporary Veterans Older Veterans
312 170 142
7.59(7.86) 10.12(8.55) 4.56 (5.62)
6.22 (6.90) 8.16(7.72) 3.90 (4.86)
6.67 (6.86) 8.45 (7.62) 4.54 (5.08)
147 165
9.27(8.15) 6.10(7.30)
7.56 (7.20) 5.03 (6.42)
7.89 (7.43) 5.58(6.13)
63 84
7.90 (7.00) 10.29(8.82)
5.92 (5.94) 8.79 (7.82)
6.90 (6.65) 8.63 (7.92)
Condition Time Time Condition Time X Condition Time Condition Time X Condition Time Condition Time X Condition
(2,620) = 116,00** (2,618) = 115.52** (1,309) = 2.62 (2,618) = 0.40
Effect Size (Between Tl and T3) Hedges ¿ 0.75
(2,618) = 115.52** (1,309) = 2.62 (2,618) = 0.40 (2,290) = 57.95** (1,145) = 4.50* (2,290) = 0.79 (2,620) = 81.00** (2,618) = 84.63** (1,309) = 0.01 (2,618) = 4.54*
0.63
(2,618) = 79.65** (1,309) = 1.45 (2,618) = 2.20 (2,290) = 33.42** (1,145) = 6.30** (2,290) = 2.58 (2,620) (2,618) (1,309) (2,618)
= 114.93** = 115.00** = 2.23 = 1.07
0.76
(2,618) = 114.50** (1,309) = 0.1 (2,618) = 0.13 (2,290) = 60.53** (1,145) = 4.13* (2,290) = 2.09 (2,622)= 13.63** (2,620) =12,42** (1,310) = 40.93** (2,620) = 5.36**
0.12
(2,620) = 14.03** (1,310) = 12.87** (2,620) = 1.38 (2,290) = 10.72** (1,145) = 3.94* (2,290) = 1.06
*p
Effect of Center-Based Counseling for Veterans and Veterans' Families on Long-Term Mental Health Outcomes Meaghan O'Donnell, PhD*; Tracey Varker, PhD*; Desmond Perry, PhDf; Andrea Phelps, PhD* ABSTRACT The Veterans and Veterans Families Counselling Service (VVCS), established by the Australian government, plays a pivotal role in providing mental health services to veterans and their families. This research explored the impact of center-based psychological counseling on depression, anxiety, stress, and alcohol use severity. A stratified sample of VVCS clients were invited to participate in this study. Data were collected on intake to the program, at the fifth counseling session, and 12 tnonths after the commencement of counseling. Repeated-measures general linear model analyses were conducted to examine the impact of center-based counseling on depression, anxiety, stress, and alcohol severity over time. VVCS center-based counseling resulted in a significant reduction in depression, anxiety, stress, and alcohol use severity after five sessions, and these itnprovements were maintained over the next 12 tnonths. Despite these improvements, however, participants continued to report tnoderate-to-severe levels of mental health problems. VVCS center-based counseling successfully reduced depression, anxiety, stress, and alcohol use sytnptom severity of veterans and their families. However, the clinical profiles of this population are often complex and challenges retnain in terms of addressing the mental health needs of this group.
INTRODUCTION It has been widely recognized that military personnel may experience rnental health issues following deployrnent. Although much attention is paid to post-traumatic stress disorder (PTSD), evidence suggests that depression, anxiety, and alcohol use disorders are just as common.' After the Vietnam War the Australian government established the Vietnam Veterans Counselling Service (VVCS). This service aimed to provide psychological care for veterans who were experiencing physical and emotional difficulties as a consequence of their military service. Today, VVCS is a primary provider of Australian community-based mental health services to veterans and their families. The service was recently renamed the Veterans and Veterans Families Counselling Service in recognition of the broader client group including contemporary (post-Vietnam) veterans and family mernbers. VVCS operates within the Department of Veteran Affairs' mental health policy frarnework focusing on improving access to a comprehensive range of mental health services for veterans and their family members.^ There are currently 15 VVCS centers across Australia that provide both individual counseling and group programs to Australian veterans, their families, and eligible Australian Defence Force personnel. Services are provided for a wide range of war- and service-related issues such as relationships and family problems, alcohol and other drugs problerns, and psychological problems such as PTSD, depression, anxiety, problematic anger, and sleep difficulties. Access to these *Australian Centre for Posttraumatic Mental Health and of Psychiatry, University of Melbourne, Level 1. 340 Albert Melbourne, VIC 3002, Australia. tVeterans and Veterans' Families Counselling Service. of Veterans' Affairs Australia, Level 6, 280 Elizabeth Street. 2010. GPO Box 3994, Sydney, NSW 2001, Australia. doi: 10.7205/MILMED-D-13-00058
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Department Street, East Department Surry Hills
services is based on self/family member refetral, or medical practitioner refeiTal. Counseling is provided by registered psychologists or social workers across a range of programs that include individual therapy, couples/family therapy, and case management. Informal client feedback indicates that the counseling interventions provided by VVCS are effective, but there has never been an independent, longitudinal examination of the impact of these VVCS center-based counseling services on rnental health outcomes. The aim of this study was to examine the outcomes of VVCS center-based counseling practiced under naturalistic conditions. These conditions include usual providers, patients, payment mechanisms, and patient/provider choice of treatment. The aim of this study was also to explore whether VVCS center-based psychological counseling resulted in sustained improvements in the mental health of veterans and their family members across time. METHOD The study protocol was approved by the Department of Veterans' Affairs Human Research Ethics Committee. The study used data routinely collected by VVCS on intake to counseling and at session five, as well as data collected for this study at 12-months after counseling. The preexisting decision to routinely collect data at session five was based on earlier VVCS data that had shown that the average period of engagement of VVCS clients was five sessions, and to standardize the time at which post-treatment data were collected and VVCS decided to choose session five. Participants Participants met entry criteria for this study if they presented to VVCS with moderate-to-severe symptoms of depression or anxiety, or alcohol misuse, and if they completed at least five sessions of VVCS center-based counseling.
MILITARY MEDICINE, Vol. 178, Decetnber 2013
Center-based Counseling Long-Term Mental Health Outcomes
A total of 4,327 veterans and their family members met entry criteria and completed the intake questionnaire between August 2009 and August 2010, Of these, 685 completed at least 5 sessions of intervention and provided data at this time point, and 312 (46%) completed the 12-month follow-up questionnaire (Fig, 1), Demographic information of the final group of 312 participants is presented in Table I, A two-staged compléter analysis was conducted to inform the generalizability of the study results. In the first analysis, those in the final group (moderate/severe self-reported depression, anxiety, or alcohol symptoms at intake, and completion of the session five assessment and 12-month follow-up assessment, n = 312) were compared to those who failed to complete outcome measures at the fifth session or 12-month follow-up (« = 4,015), The two groups differed on era of service (;i:^(l, N = 4,327) = 29,80, p < 0,001) with a smaller proportion of contemporary veterans in the study sample (52%), relative to the noncompleter group (67%), Completers also had significantly higher levels of self-reported intake anxiety than noncompleters (r(4,325) = 2,66, /; < 0,01), and higher levels of self-reported stress at intake relative to noncompleters (r(4,325) = 2,32, p < 0,05), There were no differences between the two groups in regards to gender or self-reported depression severity or alcohol use severity. In the second compléter analysis, those who completed all three assessments were compared to those who completed the intake and session five assessment but not the 12-month follow-up. Participants who completed the 12-tTionth follow-up assessment did not differ from those who did not complete it in terms of self-reported intake depression, anxiety, and alcohol
Data available from N=5495 clients' service wide
Tl: n=4327 clients met eligibility criteria tor having moderate to severe depression, anxiety or alcohol sytnptoms T2:n = 685(16%ofthe eligible sample) had fifth counselling session data available
T3: Self report questionnaires completed by n=312 clients, 12 months after intake (46% response rate) FIGURE 1.
Flow chart of clients' progression through the study.
MILITARY MEDICINE, Vol, 178, December 2013
TABLE I.
Demographic Characteristics of the Satnple (N = 312) n (%)
Gender Male Female Status Veterans Partners Sons/Daughters Defence Referred" Other'' Age Employment Currently Employed Not Cun'ently Employed Days Worked Per Week for Those Who Are Employed Type of Therapy Provided by VVCS Individual Therapy Couples Therapy Average Number of Counseling Sessions
170(54) 162(46) 128(41) 89 (29) 59(19) 19(6) 17 (5) M = 51,29(SD= 14,63) 128(41) 184(59) M = 4,46(SD= 1,42)
284(91) 26(8) M= 11.35 (SD = 6.30); Median = 10; Range = 2-40
"Australian Defence Force members who had been referred via the Defence Memorandum of Understanding, ''Those who were granted services for compassionate reasons,
use scores. Participants who completed the 12-month follow-up assessment had significantly higher levels of self-reported stress at intake (f(683) = 2,35, p < 0,05),
Measures Mental Health
The Depression Anxiety Stress Scales (DASS-21; see Reference 3), a 21-item self-report measure used to assess severity of depression, anxiety, and stress, was administered at intake, session five, and 12-month follow-up. Individuals were required to indicate the presence of a symptom over the previous week. Good levels of reliability and validity were reported, with Cronbach's a of 0,94, 0,87, and 0,91 reported for the three subscales,** Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT; see Reference 5), The AUDIT is a 10-item, self-report instrument developed by the World Health Organization as a screening tool sensitive to early detection of risky and high-risk drinking,'' A score of eight or more is associated with harmful or hazardous drinking and a score of 13 or more in women or 15 or more in men is likely to indicate alcohol dependence,^
Procedure VVCS counselors administered the intake assessment and the assessment at the end of the fifth session of counseling. The study researchers sent a self-report questionnaire that contained the DASS-21 and the AUDIT at 12 months following completion of the study (session five). Questionnaires were returned in a replied paid envelope.
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Center-based Counseling Long-Term Mental Health Outcomes Design and Statistical Analyses
In this study we used a single group design with pre-, post-, and follow-up assessments. Four sets of repeated-measures general linear model (GLM) analyses were conducted to examine whether there were changes in outcome following center-based VVCS counseling in the short term, and whether these changes were maintained over time. Outcomes for these four sets of analyses were severity of depression, stress, anxiety, and alcohol use. The primary analyses looked at differences in symptoms across time (n = 312). Secondary analyses were conducted to investigate the role of gender, client status, and era of service on changes in symptoms across time and to compare the VVCS counseling sample's 12-month depression, stress, and anxiety follow-up results to community norms. To examine the characteristics of those with moderateto-severe symptoms who responded to VVCS center-based treatment and those who did not, we conducted further exploratory analyses. A total score for affective distress was calculated (i.e., the sum of the three DASS-21 subscales), and an affective distress change score was calculated for each participant. The change score was the difference between the intake DASS-21 total score and the 12-month follow-up DASS-21 total score. To explore the degree to which participants' levels of affecfive distress improved in a clinically reliable way, we categorized paiticipants in terms of "treatment responders" and "treatment nonresponders." Clinically reliable treatment response was defined as a decrease in DASS-21 severity score of at least 15 points at 12-month follow-up (relative to intake). This reliable change index was calculated using Devilly's^ reliable and clinical change generator, which is based on the formula of Jacobson and Traux.' These authors suggest that a reliable change index larger than 1.96 (/; < 0.05) is unlikely to occur without actual change in the individual. Reliability data for DASS-21 severity used in the reliable change calculations were obtained from the thesis of McGrail,** because of the fact that reliability for the total DASS-21 score has not been previously reported by the authors of this measure. RESULTS
Depression Severity As can be seen in Table II, depression severity changed significantly over time from intake to 12-month follow-up (f (2,620) = 116.00, p < 0.001), with effect size analyses indicating that this represented a moderate-to-large clinical effect (Hedges g = 0.75). Within-subjects contrasts showed that the significant decrease in depression severity took place between intake and the fifth session (F(\,31O) = 218.51, p < 0.001), with some of the treatment gains lost by the 12-month follow-up (f (1,310) = 5.4i,p< 0.05). Despite this, however, participants were still less depressed at 12-month follow-up than when they originally started counseling. Repeated-measures GLM analyses revealed a significant
1330
main effect for era of service (F( 1,145) = 4. 40, p < 0.05). This showed that contemporary veterans were significantly less depressed than older veterans. The level of depression in the overall VVCS client group 12 months after treatment, however, was significantly greater than that of depression in a non-treatment-seeking community sample (see Table III).
Anxiety Severity Anxiety severity declined significantly over time (F(2,620) = 81.00, p < 0.001), and this represented a moderate clinical effect (Hedges g = 0.63). Within-subjects contrasts showed that there was a significant decline in level of anxiety between intake and the fifth session (F(l,310) = 128.33, p < 0.001), with these improvements being maintained over time (between the fifth session and 12-month follow-up). Analyses identified a significant interaction effect for gender on anxiety severity outcomes (see Table II), with females reporting greater improvements in anxiety severity over time (Hedges g= 0.84) than males (Hedges g= 0.46) (see Table IV). Further analyses revealed a significant main effect for era of service (/^(1,145) = 6.30, p < 0.05). Repeated-measures analyses of variance showed that contemporary veterans had much greater improvements in anxiety severity over time (Hedges g = 0.72) compared to older veterans (Hedges g = 0.36). Although this suggests that contemporary veterans as a whole were experiencing less anxiety than older veterans, generally VVCS clients had significantly greater anxiety severity at 12-month follow-up than a non-treatment-seeking community sample (see Table III).
Stress Severity Stress severity changed significantly over time (F(2,620) = 114.93, p < 0.001 ), and this represented a significant moderateto-large clinical effect (Hedges g = 0.76). Within-subjects contrasts showed that there was a significant dechne in level of stress between intake and the fifth session (F(l,310) = 201.93, p < 0.001), and this was maintained between the fifth session and 12-ir)onth follow-up. Further analyses revealed a significant main effect for era of service (f( 1,145) = 4.13, p < 0.05), with contemporary veterans experiencing less stress than older veterans. In addition, contemporary veterans had far greater improvements in stress severity over time (Hedges g = 1.00) compared to older veterans (Hedges g = 0.58). In spite of these improvements, however, overall clients had significantly greater stress severity at 12-month follow-up than a non-treatment-seeking community sample (see Table III).
Alcohol Severity The GLM analysis showed that alcohol use severity declined significantly over time (F(2,622) = 13.63,/? < 0.001), although this difference was not clinically significant (Hedges g= 0.12). Within-subjects contrasts showed that there was a significant decrease in alcohol use severity between intake and the fifth
MILITARY MEDICINE, Vol. 178, December 2013
Center-based Counseling Long-Term Mental Health Outcomes
TABLE II.
Repeated-Measures GLMs for Changes in Depression, Anxiety, Stress, and Alcohol Use Severity Score Over Time Time
Depression (Whole Sample) Males Females
Veterans Other
Contemporary Veterans Older Veterans
Anxiety (Whole Sample) Males Females
Veterans Other
Analysis
n
Intake M(SD)
Fifth Session M(SD)
12-Month Follow-up M (SD)
311 169 142
23.20(10.84) 23.73(10.69) 22.66(11.01)
13.41 (10.77) 14.00(10.63) 12.72(10.96)
14.99(11.10) 16,01 (11.31) 13.77(10.76)
147 164
23.6! (10.55) 22.91 (11.10)
13.51 (10.22) 13.33(11.30)
15.03(10.90) 14.95(11.31)
63 84
22.73(10.55) 24.26(10.56)
12.03 (9.07) 14.62(10.93)
12.70(10.50) 16.79(10.92)
311 142
17.46(10.39) 16.54(10.96) 18.55(9.63)
11.24(9.66) 11.54(10.05) 10.97(9.19)
11.19(9.57) 11.74(9.79) 10.54(9.29)
147 164
16.18(10.67) 18.61 (10.05)
10.91 (9.72) 11.61 (9.61)
11.10(9.43) 11.27(9.72)
169
(dlIF
Time Time Condition Time X Condition Time Condition Time X Condition Time Condition Time X Condition Time Time Condition Time X Condition Time Condition Titne X
Contemporary Veterans Older Veterans
63 84
15.33(10.85) 16.81 (10.54)
8.44 (7.75) 12.76(10.65)
8.48 (7.88) 13.07(10.04)
Condition Time Condition Time X
Stress (Whole Sample) Males Females
Veterans Other
Contemporary Veterans Older Veterans
311 169 142
26.48 (9.72) 26.83 (9.96) 26.06 (9.45)
17.84(10.52) 18.25(10.65) 17.35(10.37)
18.77(10.50) 19.87(10.96) 17.45(9.81)
147 164
26.52 (9.67) 26.44 (9.80)
17.59(10.38) 18.06(10.67)
18.82(10.87) 18.72(10.19)
63 84
26.10(8.79) 26.83(10.33)
15.81 (8.45) 18.93(11.26)
16.32(10.58) 20.69(10.78)
Condition Time Time Condition Time X Condition Time Condition Time X Condition Time Condition Time X
Aleohol Use (Whole Sample) Males Females
Veterans Other
Contemporary Veterans Older Veterans
312 170 142
7.59(7.86) 10.12(8.55) 4.56 (5.62)
6.22 (6.90) 8.16(7.72) 3.90 (4.86)
6.67 (6.86) 8.45 (7.62) 4.54 (5.08)
147 165
9.27(8.15) 6.10(7.30)
7.56 (7.20) 5.03 (6.42)
7.89 (7.43) 5.58(6.13)
63 84
7.90 (7.00) 10.29(8.82)
5.92 (5.94) 8.79 (7.82)
6.90 (6.65) 8.63 (7.92)
Condition Time Time Condition Time X Condition Time Condition Time X Condition Time Condition Time X Condition
(2,620) = 116,00** (2,618) = 115.52** (1,309) = 2.62 (2,618) = 0.40
Effect Size (Between Tl and T3) Hedges ¿ 0.75
(2,618) = 115.52** (1,309) = 2.62 (2,618) = 0.40 (2,290) = 57.95** (1,145) = 4.50* (2,290) = 0.79 (2,620) = 81.00** (2,618) = 84.63** (1,309) = 0.01 (2,618) = 4.54*
0.63
(2,618) = 79.65** (1,309) = 1.45 (2,618) = 2.20 (2,290) = 33.42** (1,145) = 6.30** (2,290) = 2.58 (2,620) (2,618) (1,309) (2,618)
= 114.93** = 115.00** = 2.23 = 1.07
0.76
(2,618) = 114.50** (1,309) = 0.1 (2,618) = 0.13 (2,290) = 60.53** (1,145) = 4.13* (2,290) = 2.09 (2,622)= 13.63** (2,620) =12,42** (1,310) = 40.93** (2,620) = 5.36**
0.12
(2,620) = 14.03** (1,310) = 12.87** (2,620) = 1.38 (2,290) = 10.72** (1,145) = 3.94* (2,290) = 1.06
*p
